Archives: Medical Student Finals

MSFinals-6723

A 38-year-old woman presents to the Emergency Department (ED) with chest and abdominal pain, following three days of severe vomiting secondary to gastroenteritis. She reports pain being worse on swallowing and feels short of breath. On examination, she looks unwell and has a heart rate of 105 bpm, a blood pressure of 110/90 mmHg, a respiratory rate of 22 breaths/minute and a temperature of 38 °C. Boerhaave syndrome is suspected.
What is the most appropriate initial investigation, given the suspected diagnosis?

MSFinals-6719

A 50-year-old woman presents with acute right upper quadrant abdominal pain and vomiting, which started earlier today.
On examination, the patient is not jaundiced and there is mild tenderness in the right upper quadrant and epigastrium. The blood results are as follows:
Investigation Result Normal value
Haemoglobin 130 g/l 115–155 g/l
White cell count (WCC) 14 × 109/l 4–11 × 109/l
Sodium (Na+) 138 mmol/l 135–145 mmol/l
Potassium (K+) 4.0 mmol/l 3.5–5.0 mmol/l
Urea 6.0 mmol/l 2.5–6.5 mmol/l
Creatinine 70 μmmol/l 50–120 μmol/l
Bilirubin 25 mmol/l 2–17 mmol/l
Alkaline phosphatase 120 IU/l 30–130 IU/l
Alanine aminotransferase (ALT) 40 IU/l 5–30 IU/l
Amylase 200 U/l < 200 U/l
Which of the following is the most appropriate management plan?

MSFinals-6718

A 54-year-old man presents to the Emergency Department complaining of right upper quadrant and epigastric pain and associated vomiting. This is his third attack in the past 9 months. He has a past history of obesity, hypertension and hypertriglyceridaemia. Medications include ramipril, amlodipine, fenofibrate, aspirin and indapamide. On examination, he is obese with a body mass index (BMI) of 31; his blood pressure is 145/85 mmHg, and he has jaundiced sclerae. There is right upper quadrant tenderness.
Investigations:
Investigation Result Normal value
Sodium (Na+) 140 mmol/l 135–145 mmol/l
Potassium (K+) 3.9 mmol/l 3.5–5.0 mmol/l
Creatinine 140 μmol/l 50–120 µmol/l
Haemoglobin 139 g/l 135–175 g/l
White cell count (WCC) 10.1 × 109/l 4–11 × 109/l
Platelets 239 × 109/l 150–400 × 109/l
Alanine aminotransferase 75 IU/l 5–30 IU/l
Bilirubin 99 μmol/l 2–17 µmol/l
Alkaline phosphatase 285 IU/l 30–130 IU/l
Ultrasound of abdomen: gallstones clearly visualised within a thick-walled gallbladder, dilated duct consistent with further stones.
Which of his medications is most likely to be responsible for his condition?

MSFinals-6722

A 23-year-old woman developed sudden-onset, severe epigastric pain 12 hours ago. She subsequently began having episodes of nausea and vomiting, especially after trying to eat or drink. The pain now feels more generalised, and even slight movement makes it worse. She has diminished bowel sounds and exquisite tenderness in the mid-epigastrium with rebound tenderness and board-like rigidity. Her pulse is 110 bpm and blood pressure 130/75. She reports taking ibuprofen for dysmenorrhoea. She had last taken ibuprofen the day before the pain began.
What is the most likely diagnosis?

MSFinals-6721

A 44-year-old man with diagnosed primary sclerosing cholangitis (PSC) had been taking cholestyramine and vitamin supplementation for the last 3 years. He had ulcerative colitis which was in remission, and colonoscopic surveillance had not shown any dysplastic changes. His only significant history was two episodes of cholangitis for which he had to be hospitalised in the past year. On examination, he was mildly icteric with a body weight of 52 kg. At present, he had no complaints, except fatigue.
What is the next best treatment option?

MSFinals-6715

A 55-year-old man presents to the general practitioner (GP) with a 6-month history of increasing difficulty with swallowing solid foods. He does not have any problems with swallowing liquids. He has always been overweight but has lost 5 kg in the past few months. He attributes this eating a little less due to his swallowing difficulties. He has a past history of long-term heartburn and indigestion, which he has been self-treating with over-the-counter antacids. The GP is concerned that the patient may have oesophageal cancer.
Which one of the following statements with regard to oesophageal cancer is correct?

MSFinals-6724

A 67-year-old woman complains of epigastric pain, vomiting and weight loss. The surgeon suspects gastric cancer and sends her for endoscopy. Where is the cancer likely to be located?

MSFinals-6708

A 23-year-old man was stabbed with a knife and brought to the Emergency Department, with the knife still in the left posterolateral side of his body. The knife entered the intercostal space between the left ninth and tenth ribs, 10 cm posterior to the mid-axillary line.
What is the most likely structure to have been damaged first by the knife?

MSFinals-6703

A 48-year-old woman is brought to the Emergency Department following a motor vehicle accident. The patient’s car was parked in the street when a small car hit her vehicle from behind. She was seated and restrained in the driver’s seat and was not ejected from the vehicle. The airbags did not deploy. The ambulance staff reported that the patient did lose consciousness at the scene but now is alert and orientated.
Her primary and secondary surveys are normal. Her neurological examination is also normal and she has full cervical spine range of motion. The patient has a Glasgow Coma Scale of 15/15.
Her observations and blood tests results are shown below.
Temperature 36.9 °C
Blood pressure 121/59 mmHg
Heart rate 67 beats per minute
Respiratory rate 18 breaths per minute
Sp(O2) 98% (room air)
Her computed tomography (CT) scan of the head, cervical spine, chest, abdomen and pelvis is normal. She is still complaining of diffuse, muscular pain throughout her body which was not present before the accident. She is able to mobilise slowly around the ward. She states that prior to the accident she was able to mobilise independently without difficulty and without pain.
Which of the following is the most likely diagnosis?

MSFinals-6701

A patient in their mid-40s is transferred from a District General Hospital to the Burns and Trauma Centre. They arrive intubated. The history is that they were on some scaffolding holding a pole, which they touched onto an overhead powerline, causing electrocution. They fell backwards and were found to be in ventricular fibrillation (VF) arrest by paramedics, who resuscitated them with defibrillation. They have small burns on their hands and also their left foot. On arrival at the Trauma Centre, they have a full CT traumagram which showed no other injuries. Their C-spine has been radiologically cleared. You are examining them, and you notice they have a swollen, tight left leg. The nurse brings you their blood gas, and you see they have a potassium level of 6.3 and they have mild metabolic acidaemia, with a pH of 7.21. Their urine is tea-coloured (catheter in situ), with a creatine kinase (CK) level of 1232.
What is the best course of action?